Biomedical Engineering Society of India

Application Form for Life Membership

Name in full:

Nationality:

Place of Birth:

Date of Birth:

Address
A. Office:

B. Home:

E-mail Id:
Please tick the address preferred for mailing: Office

Home

Present position, Length of Service and Responsibilities:

Nature of experience and interest in Biomedical Engineering including publications:

(Attach additional sheets if necessary)

Education (Degree, Year of passing etc):

Membership of other professional organisations:

I certify that the statements on this application are correct and agree to abide by the rules and
bylaws of the society.

Date:
Signature of Applicant
Note: Application money payable with this form: Life Membership Subscription Rs 1500/-+Rs
20/Details of payment:
D D No.

Bank:

Demand Drafts should be made payable to the BIOMEDICAL ENGINEERING SOCIETY OF

INDIA, payable at Udupi or Manipal. Completed application form together with payment
should be sent to:
Mr. Muralidhar Bairy G, Joint Secretary, BMESI,

Deprtment of Biomedical Engineering,

Manipal Institute of Technology, Manipal-576104
FOR OFFICE USE
Application Received on:
Member Receipt No:

Sent on:

Membership No:
Elected on: